report

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Mental Health Consultation
Patient Name: Intracerebral hemorrhage Facility: XXXX
leading to Wernicke's aphasia & partial seizures
Date: x-xx-xx
For the sake of brevity and timeliness, the following sections will not be included in this report:
Background Information: Current Medications: Medical History: That information can be
found elsewhere in this chart.
Reasonfor Referral: Left-handed, xx-year-old, white, married, female… I was asked to
evaluate her in connection with a hemorrhagic stroke. While she was in xxxxx with her husband,
on x-x-xx she suffered a left intracerebral hemorrhage which subsequently required a left
parietal-occipital craniotomy. Later neuroimaging showed a large area of low attenuation in the
left occipital lobe and the posterior left parietal lobe; small vessel disease; a remote old lacunar
infarct; and diffuse cerebral and cerebellar volume loss.
Following her acute stroke care she was sent to the Xxxxx Rehabilitation Xxxxx for a couple of
months then to xxxx Hospital and finally to us. Shortly after the onset of her stroke she was
described as globally aphasic with poor impulse control; “she grabbed a nurse by the throat”
and was described by family members as “narcissistic, irritable, verbally abusive, controlling
and argumentative”. She was initially admitted from xxxxx Hospital on x-xx-xx. More recently
she was admitted to XXXX where she was diagnosed with partial seizures. As far as I can tell,
she has not exhibited any aggressive behavior at XXXX. She is not taking any psychiatric
medications.
Mental Status Exam: I interviewed her with her husband present. She was a well-groomed,
cooperative and pleasant, gray-haired lady with a distinct Wernicke’s type aphasia. Unlike most
Wernicke’s patients she did not take offense when told that much of her speech made no sense.
She responded, “I used to get angry and frustrated about that but not so much anymore”. She
was also able to laugh about it. However, about 50% of her speech was relevant and coherent.
Her affect was full and appropriate. She denied depression and disinhibition. Her husband
confirmed this. However, she did very poorly on my simple tests of speech comprehension using
yes or no questions. She also clearly had severe memory problems. She did not know how many
children she had; what their names were or much at all about them. Her main complaint was she
felt that she has made little progress in rehabilitation and she has had two “severe setbacks”. She
had moderate weakness on the right side. Her orientation was limited to name only. She did not
know the date, the month, year, her own age or her date of birth. Her insight and judgment were
impaired. She exhibited pronounced apraxia and anomia.
Findings and Recommendations: Obviously, based on symptoms, despite her left handedness
and the fact that three of her children are left-handed she is not familial left-handed and therefore
left hemisphere dominant for language. Based on a fairly brief contact and a thorough review of
her history but without any of the important documents from her rehab at Xxxxx, I can offer the
following limited impressions: She evidently had a hemorrhagic stroke. She had an intracerebral
hemorrhage. Bleeding into the substance of the brain and/or the ventricles may cause an
elevation of intracranial pressure which can produce profound lasting deficits like the gross
confusion we see in her presentation. Intracerebral hemorrhage has a predilection for certain sites
in the brain, including the thalamus, putamen, cerebellum, and brainstem; in addition, to the

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areas of the brain directly injured by the hemorrhage. The surrounding brain tissue can be
damaged by pressure produced by the mass effect of the bleeding. Also a general increase in
intracranial pressure may occur which can lead to damage in wide spread areas of the brain.
Seizures are more common in hemorrhagic stroke than in ischemic stroke and occur in 28%
of cases of hemorrhagic stroke. We know that she is one of the 28%. On the whole, the lasting
effects of hemorrhagic stroke are much worse than they are for ischemic stroke. In her case, the
pressure was high enough to require a left parietal-occipital craniotomy. Typical lasting
symptoms and consequences of hemorrhagic stroke include the following: decreased social
interaction, decreased ability to function or care for oneself, decreased life span, difficulty
communicating, joint contractures, muscle spasticity, permanent loss of cognitive or other
brain functions (dementia), permanent loss of movement or sensation of one or more parts of
the body, pressure sores due to lack of movement, urinary and respiratory tract infections.
She appears to have a Wernicke's type aphasia which is a language disorder that impacts language
comprehension and the production of meaningful language. Individuals with Wernicke's aphasia
have difficulty understanding spoken language but are fluent and able to produce sounds, phrases,
and word sequences. While these utterances have the same rhythm as normal speech, they are
mostly not language and empty of meaning. Receptive aphasia involves damage to the area of the
cortex known as Wernicke’s area in the posterior area of the cerebral cortex. A patient with
receptive aphasia is usually unaware of the deficits and can become angry with others for not
understanding their incoherent utterances. Spontaneous improvement in speech for stroke victims
generally occurs during the first ten weeks post CVA. Some spontaneous improvement will be
seen up to 18 months after a CVA.
Her previous aggressive behavior may have been driven by frustration associated with expressive
aphasia and the consequent inability to express anger and other emotions in words. Her family
seemed to describe her as having a premorbid personality disorder. Much of the data suggests
that she had a premorbid mild vascular dementia.
1. Psychotropic medication is not likely to be of much benefit in this situation.
2. Quite a bit of historical material was available in her chart but none of it appeared to be
from Xxxx. I presume a thorough neuropsychological evaluation was done there and we
need the results of that evaluation. The couple seemed uninformed about nature and
consequences of her stroke. It will fall to us explain this to them.
3. Staff should help her compensate for memory loss by:
a. Assisting her with the creation of a memory log which includes:
1) Autobiographical information
2) Facts about the facility
3) A detailed daily schedule
4) A calendar with scheduled appointments, activities, therapies etc.
5) A things to do list
6) A list of names of frequently encountered people with identifying
information.
b. Repeat important information/instructions many times each day. Try to use
the same simple words and phrases each time.

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4. Avoid complex demands or tasks which can lead to frustration and use praise liberally
when her behavior is appropriate.
5. Staff should always try to communicate important information using the same language.
Staff might consider creating a list of sentences to use when responding to her questions.
6. To improve awareness of deficits, tell her about her speech and language deficits and
how they impact her daily life. This must be presented in a non-judgmental fashion.
7. Avoid ambiguity, and do not present her with unnecessary choices or decisions. Use
statements such as “Now it is time to take a shower”.
8. Be sure to allow her enough time to communicate when she is struggling to speak and
offer cues when necessary.
9. When interacting with her:
 Limit the use of questions but when you must ask a question keep to the here and now
and word your questions so they can be answered yes or no.
 Give one direction or ask one question at a time.
 Start each conversation by identifying yourself and use short, simple sentences with
familiar words. Smile and use gentile touch.
 Avoid presenting her with decisions by using no choice instructions.
 Avoid “why” questions.
 Look directly at her, speak slowly and distinctly.
 Point and use gesture. Encourage her to point and use gesture.
 Use touch and eye contact to calm her.
 Announce any physical contact before touching her.
 Always approach her from the front.
 When she is agitated, tell her you understand that she frustrated because others cannot
understand her.
10. Establish a predictable and consistent daily routine for her. Keep her busy with simple tasks
but not excessively stimulated. Track her daily fluctuations in arousal and schedule the
most demanding activities when she is typically at peak arousal levels. Schedule frequent
rest periods but no naps throughout the day.
11. Have her practice the following:
 Trying to get her point across no matter what anybody says or thinks.
 Asking people to slow down when they speak.
 Engaging in more one-on-one conversations.
 When talking with a new person say, “I had a stroke…can you understand me?”
 Go out more often and interact with many people, socialize.
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Drew Chenelly, Psy.D. This document was created using voice recognition software.
Clinical Neuropsychologist